<?
if (!defined('MODULE_FILE')){
die ("cant access file directly!");
}

$mid=$_GET['mid'];
$smid=$_GET['smid'];
$emp_id = $_SESSION['SESS_MEMBER_ID'];
?>
<html>
<head>
<?php require_once 'commonJS.php'; ?>
</head>
<body>
<br>
<div class="col-lg-8">
<div class="panel panel-primary">
<div class="panel-heading"><i class="fa fa-bell fa-fw"></i>Patient Address</div>
<div class="panel-body">
	<form METHOD="POST" action="modules.php?file=redcarddata&mid=<? echo $mid; ?>&smid=<? echo $smid; ?>" id="formSubmit" name="formSubmit" >
	
	<input id="empid" Name="empid" type="hidden"  value="<?php echo $emp_id;?>">
	<input type="hidden" id="redid" Name="redid" value="<?php echo $rcdID;?>">
	
		<table width="80%" cellspacing="0" cellpadding="3">

			<tr><td height="10" colspan="2"></td></tr>
			<tr valign="top">
				<td class="mandatory" width="220">Patient ID</td>
				<td>
				<select class="validate[required]" name="patient_id" id="patient_id" style="width:202px;">
						<option value=""> -- please choose -- </option>
				</select>
			  </td>
			</tr>
			<tr><td height="10" colspan="2"></td></tr>
			<tr valign="top">
				<td class="desc" width="220">Address1</td>
				<td><textarea name="address_line1" rows="5" cols="40"></textarea></td>
			</tr>
			<tr><td height="10" colspan="2"></td></tr>
			<tr valign="top">
				<td class="desc" width="220">Address2</td>
				<td><textarea name="address_line2" rows="5" cols="40"></textarea></td>
			</tr>
			<tr><td height="10" colspan="2"></td></tr>
			<tr valign="top">
				<td class="mandatory" width="220">Area</td>
				<td><input id="area" Name="area" type="text" class="validate[required]" style="width:202px;" value=""></td>
			</tr>
			<tr><td height="10" colspan="2"></td></tr>
			<tr valign="top">
				<td class="mandatory" width="220">Pincode</td>
				<td><input id="pin_code" Name="pin_code" type="text" class="validate[required]" style="width:202px;" value=""></td>
			</tr>
			<tr><td height="10" colspan="2"></td></tr>
			<tr valign="top">
				<td class="mandatory" width="220">Street</td>
				<td><input id="street_details" Name="street_details" type="text" class="validate[required]" style="width:202px;" value=""></td>
			</tr>
			<tr><td height="10" colspan="2"></td></tr>
			<tr valign="top">
				<td class="mandatory" width="220">Address Type</td>
				<td>
				<select class="validate[required]" name="address_type" id="address_type" style="width:202px;">
						<option value=""> -- please choose -- </option>
				</select>
			  </td>
			</tr>
			<tr>
				<td colspan="2" height="10px"></td>
			</tr>
			<tr valign="top">
				<td class="mandatory" width="220">&nbsp;</td>
				<td><input type="submit" value="SUBMIT" id="Submit" name="Submit"></td> 				
			</tr>
		</table>
</div>
</div>
</div>	
</form>
</body>
</html>